Barriers and Strategies for Early Mobilization of Patients ... and Strategies for... · Nydahl 2013 (16) Preval ence study Ger. 116 ICUs, different hospitals 116 mixed ICUs, n=783,

Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units

Rolf Dubb1*

, Peter Nydahl2*

, Carsten Hermes3, Norbert Schwabbauer

4, Amy Toonstra

5, Ann

M. Parker6, Arnold Kaltwasser

1, Dale M. Needham

7

1Department of Continuing Education of Critical Care Nursing, District Hospital of

Reutlingen, Reutlingen, Germany; 2Neurological ICU and Stroke Unit, University Hospital of

Schleswig-Holstein, Kiel, Germany; 3Intensive Care Unit, Helios Klinikum Siegburg, Siegburg,

Germany; 4Department of Medicine, University Hospital Tubingen, Tubingen, Germany;

5Physical Medicine and Rehabilitation, Johns Hopkins Hospital,

6Division of Pulmonary and

Critical Care Medicine, Johns Hopkins University School of Medicine, 7Pulmonary and Critical

Care Medicine, Johns Hopkins University, Baltimore, MD

*These authors contributed equally to the work and should be considered co-first authors

Corresponding Author:

Peter Nydahl

University Hospital of Schlweswig-Holstein - Nursing Research

Brunswiker Str. 10 Kiel 24105

Germany

Key Words: Critical Care; Intensive Care; Quality; Rehabilitation; Physical Therapy; Review

Word Count: 2135

Page 1 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR

Copyright © 2016 by the American Thoracic Society

Abstract

Early mobilization of patients in the intensive care unit (ICU) is safe, feasible, and beneficial.

However, implementation of early mobility as part of routine clinical care can be

challenging. The objective of this review is to identify barriers to early mobilization and

discuss strategies to overcome such barriers. Based on a literature search, we synthesize

data from 40 studies reporting 28 unique barriers to early mobility, of which 14 (50%) were

patient-related, 5 (18%) structural, 5 (18%) ICU cultural and 4 (14%) process-related

barriers. These barriers varied across ICUs and within disciplines, depending on the ICU

patient population, setting, attitude, and ICU culture. To overcome the identified barriers,

>70 strategies were reported and are synthesized in this review, including: implementation

of safety guidelines; use of mobility protocols; interprofessional training, education, and

rounds; and involvement of physician champions. Systematic efforts to change ICU culture

to prioritize early mobilization using an interprofessional approach and multiple targeted

strategies are important components of successfully implementing early mobility in clinical

practice.

Abstract Word Count: 165



For patients in intensive care units (ICUs), bed rest and prolonged immobility commonly

occur and increase the risk of ICU-acquired weakness and other complications (1,2). Early

mobilization of ICU patients has been associated with improved muscle strength and

functional independence, as well as a shorter duration of delirium, mechanical ventilation,

and ICU length of stay (3-7). Despite the safety and feasibility of early mobilization (8-13),

most ICU patients remain immobilized for long periods of time (14-18). Several prior

publications have reported modifiable and non-modifiable barriers to early mobilization

(10,19-21). Understanding such barriers, and associated strategies to overcome them, is

helpful for clinicians wanting to implement early mobility as part of routine clinical practice.

Hence, the objective of this literature review is to synthesize published data on

barriers to early mobilization of ICU patients and associated strategies used to address these

barriers. The information presented in this review here is based on a structured search of

the literature using PubMed, Cumulative Index to Nursing and Allied Health Literature

(CINAHL), Physiotherapy Evidence Database (PEDro), and Cochrane Central Register of

Controlled Trials, along with a review of the reference list from relevant studies.

Included studies were analyzed for descriptions of barriers and associated strategies

to overcome those barriers. Two authors independently categorized each barrier and

strategy. In the event of uncertainty in categorization, consensus among all authors was

used. To facilitate future quality improvement projects, reported barriers were organized

into 1 of 4 categories: 1) patient-related barriers, including patient symptoms and

conditions (e.g., hemodynamic instability); 2) structural barriers, including human and

technical resources (e.g., staffing, equipment or protocols); 3) barriers related to ICU

culture, including habits, attitudes, and context within ICUs and institutions (e.g. staff



morale); and 4) process-related barriers, including how services are delivered and clinician

functioning (e.g. unclear roles and responsibilities).

ICU patients may have absolute contraindications (e.g. unstable fracture) that limit

mobilization and thus do not represent a modifiable barrier. If no strategy was reported to

address such a condition, it was classified as a contraindication, rather than a barrier.

Barriers were categorized into a) prospectively defined and empirically evaluated, using

specific criteria (e.g. high oxygen fraction), and b) perceived barriers (defined as those

without defined criteria determined based on perceptions arising from team meetings, staff

interviews or personal reflection), or c) a mix of both.

Strategies described within studies reporting barriers were abstracted, synthesized,

and categorized according the type of barrier(s) it addressed. When a strategy was reported

to address >1 category of barrier, it was listed with each category and designated, in the

tables, as a strategy used for multiple barriers. The success of these strategies at

overcoming barriers was classified as follows: (1) objective measurement (defined as having

at least one of the included studies demonstrating that the strategy was successful in

improving mobility rates); (2) subjective opinion (defined as having at least one of the

included studies in which the authors concluded, based on their opinions, the strategy was

important in addressing barriers to mobility); and (3) clinician survey (defined as clinicians

being surveyed/interviewed for their opinion about success).

Barriers and Strategies

From 40 studies identified via the structured literature search (9-16,19-50), a total of 28

unique barriers were identified: 14 (50%) patient-related, 5 (18%) structural, 5 (18%) related



to ICU culture, 4 (14%) process-related (Tables 1-4). We identified 3 contraindications to

mobility, as previously defined: orthopedic or surgical issues, active hemorrhage or

coagulation issues, and cognitive impairment (e.g. coma).

Prospectively defined and empirically evaluated barriers, as previously defined, were

found in 17 studies (9,11,13-16,19,23-25,27-29,34,35,41,50), perceived barriers in 19

studies (12,20-22,26,31-33,36-39,43-49) and a mix of both in 4 studies (10,30,40,42) (Table

E1). Only 1 study used a validated instrument for the assessment of barriers (37), while

other studies identified barriers using a variety of techniques, including interdisciplinary

meetings (10,12,21,30,42) and interviews or custom-made surveys with clinicians

(19,28,38,44,45,47,48,49).

In summary, 68 (93%) of 73 strategies addressed more than one barrier. For

example, a protocol for early mobilization addressed barriers that included hemodynamic

instability, respiratory instability, and physician order for bed rest.

Patient-Related Barriers and Strategies

Patient-related barriers were reported by 31 (77%) of the relevant studies and included 14

unique barriers and included physical, neuropsychological, and ICU devices and equipment

barriers. The most common patient-related barrier was hemodynamic instability (n=20,

50% of studies) followed by vascular access devices, tubes and drains (n=18, 45%). Other

patient-related barriers included sedation or decreased level of consciousness, and patient

illness- and treatment-related factors (Table 1).

Strategies to address patient-related barriers were reported in 27 (67%) of the

studies. These strategies included: using an interdisciplinary approach to enhance early

mobilization in 20 (50%) studies, development and implementation of protocols in 18 (45%)



studies, and defining inclusion and exclusion criteria for mobility in 7 (17%) studies, while 14

(42%) studies used others strategies. Notably, some authors performed their own studies or

quality improvement evaluations to address specific barriers, such as conducting surveys

(41,44,45,48) or systematically evaluating the safety and feasibility of early mobilization in

special circumstances, such as presence of femoral lines (29,39), renal replacement therapy

(12,43), or extracorporeal membrane oxygenation (13).

Structural Barriers and Strategies

Structural barriers were reported by 28 (70%) studies and included limited staff in 18 (45%)

of studies, lack of an organized program for early mobility in 14 (35%), and inadequate staff

training in 10 (25%) studies (Table 2).

Strategies to overcome structural barriers were identified in 25 (62%) studies and

included: development and implementation of protocols in 20 (50%) studies, increased

staffing in 18 (45%), and purchase of equipment in 12 (30%) studies. In particular,

interprofessional protocols were created to help with identifying appropriate patients for

early mobility and coordinating patient mobilization. Other strategies included staff training,

regular interprofessional staff meetings, and changes in clinical documentation to permit

better evaluation of early mobilization of patients.

ICU Culture-Related Barriers and Strategies

Barriers related to ICU culture were reported in 24 (60%) of studies. Such barriers included

14 (35%) studies reporting an attitude that does not view early mobility as a priority;

inadequate staff knowledge regarding the benefits, safety, and techniques of mobility in 12

(30%) studies; and low staff morale in 10 (25%) studies (Table 4).



Strategies to overcome ICU cultural barriers were identified in 24 (60%) of included

studies. These strategies included education (e.g., training, sharing literature, videos, etc.)

and training (hands-on, bedside teaching, etc.) in 18 (45%) of studies. In 8 (20%) studies,

decision-making processes were changed and included improved coordination between

professions to allow for collaborative goal-making, as well as increased nurse and physical

therapist involvement. Timely feedback about successes with patient mobilization was also

important (30,31).

Process-Related Barriers and Strategies

Process-related barriers were identified in 24 (56%) studies. The most common such

barriers were lack of coordination (e.g., lack of consistent interprofessional rounds or

coordination of patient procedures with mobilization) in 16 (40%) studies, and missing or

delayed screening to identify patients appropriate for mobility in 15 (37%) studies. Unclear

job expectations, roles, and responsibilities were reported by 10 (25%) studies (Table 3).

Differences between physical therapists and nurses in their assessments of patient

appropriateness for mobilization, and lack of communication between these professions,

led to different levels of patient mobilization (28).

Strategies to overcome process-related barriers were identified in 25 (62%) of

studies. Such strategies included implementing interprofessional meetings and rounds in 18

(45%) studies, sharing clinical responsibilities in 15 (37%) studies, and collaboration with

champions to promote early mobilization in 12 (30%) studies. Methods to reduce the time

to a physician order for mobilization, such as use of an automatic order or removal of

default order for bed-rest, shortened the time to first mobilization (10,26).



Discussion

In this focused review of barriers and strategies for early mobilization of ICU patients, 28

unique patient, structural, process-related, and ICU cultural barriers were identified, with

patient-related barriers being the most common category. More than 70 strategies to

overcome these barriers were identified and synthesized.

Existing literature on the safety of early mobilization provides evidence to address

some perceived patient-related barriers, such as safety concerns regarding presence of an

endotracheal tube, modest doses of vasopressors or hemodynamic instability (9,10,27).

Since the definition of hemodynamic “instability“ is subjective (51), without any clear

consensus for thresholds of vasopressor doses that are safe for mobilization (52), use of

unit-specific protocols developed based on local consensus may be helpful in systematically

addressing this potential barrier.

Some factors identified as “contraindications” (as defined above), such as unstable

spinal fracture and active bleeding may appropriately limit mobilization of ICU patients.

Nevertheless, other factors identified as “contraindications” in this review (e.g., coma) may

not be absolute contraindications, with some arguing, for instance, that mobilization of

patients with coma would stimulate increased awareness (53). In general, mobilization and

identification of barriers may depend on which profession was surveyed (28,38,44-47).

Therefore, a multiprofessional approach that utilizes both qualitative and quantitative data

may be optimal for identifying barriers and potential strategies to overcome them (54).

Common structural barriers included limited staffing and lack of protocols and staff

training. Physical therapists identified lack of physical therapists as a barrier (22,44) and

nurses also reported the same barrier for their own profession (36,44). Recruiting additional



staff may assist with this specific barrier (55). Morris et al (23) reported that the financial

benefits to a hospital, via a reduced length of stay, compensated for the additional costs

required for staffing a mobility team. Needham et al (10) demonstrated a financial benefit

for the hospital through reduced length of stay and increased admissions to the ICU.

The potential financial benefit of implementing early mobilization has been

evaluated through a financial model (55) that may assist clinicians and hospital

administrators who are considering creating an ICU-based mobilization program. Such

financial modeling and associated business cases have facilitated expansion of staff for early

mobility programs in other institutions (20). However, additional staff may not always be

required if other strategies are used to address the staffing barrier.

Bailey et al. reported mobility activities on 88% of their ICU days without a higher

patient-staff ratio, given that they established an ICU culture that prioritized early mobility

(9). Other studies found no relationship between staffing and mobility level (16,20). The

ideal staff to patient ratio for a successful early mobilization program remains unclear.

Other issues (e.g. safety concerns, staff expertise, division of responsibilities) may be as

important as staff to patient ratio (44,46). For instance, there are significant differences in

barriers between ICUs with and without mobility practice; hence, barriers may change with

experience (47,48). Even with expanded staffing, early mobility protocols and staff training

may be important additional strategies necessary for overcoming barriers (47,56).

Barriers related to ICU culture are a systematic issue that can be time-consuming and

challenging (24, 57) to overcome. However, successful change of ICU culture may result in

changes that are sustained for several years (58). The most common strategies to address

these cultural barriers included multiprofessional education, mobility champions, mobility

protocols, daily interprofessional rounds, and documentation that allows evaluation of



mobility efforts (59). In addition, the development and documentation of daily

interprofessional goals (10,25, 59) and sharing of improved patient outcomes (59) may be

beneficial. However, sustainability of early mobility programs may be hampered by

organizational changes such as staff turnover or change in leadership (37). At a minimum,

identifying barriers is an important first step for implementing change

(10,14,20,44,45,48,49).

Common process-related barriers included a lack of communication and unclear

delineation of staff roles for patient mobilization (9,10,19,21,23,27,30-32,34-

38,42,44,45,47). Interprofessional rounds, checklists and protocols, along with leadership

from an identified champion with available time may improve early mobilization. Timely

feedback about the frequency of early mobility that is actually occurring, potential safety

events, and sharing success stories may improve motivation and prioritization of early

mobilization (47,60). Concerns regarding staff safety emphasize the importance of

appropriate training, equipment, and planning (44).

Early mobilization in the ICU is associated with improved patient outcomes.

Successful implementation of early mobility depends on patient status, and ICU-related

processes, structures, and culture. This review identifies potential barriers to early mobility

as well as strategies to address those barriers, which may be helpful to future clinicians as

they implement early mobility programs in the ICU. A multiprofessional approach to early

mobility implementation and a change in ICU culture, making early mobility a high priority,

are especially important. Barriers and strategies may change during the implementation

process, indicating a need for ongoing, interprofessional reflection and evaluation.



Conclusions

Barriers to early mobilization of ICU patients are multi-faceted, with patient-related barriers

being most commonly cited. Studies have identified numerous practical strategies that have

been successful in addressing most perceived barriers to early mobilization. Systematic

efforts to change ICU culture to prioritize early mobilization using an interprofessional

approach and multiple targeted strategies are important components of successfully

implementing early mobility in clinical practice.



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58. Dinglas VD, Parker AM, Reddy DR, Colantuoni E, Zanni JM, Turnbull AE, Nelliot A, Ciesla

N, Needham DM. A quality improvement project sustainably decreased time to onset of

active physical therapy intervention in patients with acute lung injury. Ann Am Thorac

Soc. 2014 Oct;11(8):1230-8.

59. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving

communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-5.

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sustaining an early rehabilitation program in a medical intensive care unit: A qualitative

analysis. J Crit Care. 2015;30(4):698-704.



Table 1. Patient-related barriers to early mobilization and related strategies to overcome

barriers

Barriers Strategy

Physical barriers

High severity of illness, patients “too sick”

or “too well”

Interprofessional meetings†*; PT screening of ICU

patients†*

32,41,42,46

Hemodynamic instability, arrhythmias

Stepwise approach†‡

*; protocols†‡

*; safety criteria†‡

*; avoid

mobilization until 2 hours after increase in vasopressor

dose†*, valid assessment

†‡*

9,10,19,23,24,26,31,44,46,48,50

Respiratory instability/distress, ventilator

asynchrony

Stepwise approach to mobility including a safety check after

each step†‡

*; protocol for standardized mobilization

including safety criteria†‡

*; adjust FiO2, PEEP, or other

ventilators settings for mobilization†*

9,10,19,24,26,31

Pain Screen for pain†*; provide pain medication prior to

mobilization†*

10,48

Poor nutritional status Perform nutritional screening‡*

38

Obesity (e.g. BMI ≥30) Use protocol for standardized mobilization†‡

* 33,47,48

Baseline or new immobility/weakness Initiate mobility within 24 hours of admission†*; re-evaluate

daily†*; Consult neurology

†*

10,24

Neuropsychological barriers

Deep sedation and/or paralysis Perform routine assessments of sedation and pain†*; target

lighter sedation goals†*; avoid medications with long half-

lives†‡

*, interprofessional approach‡*

10,19,44,46-48,50

Delirium, agitation Delirium screening†*; use of antipsychotics

†*; reduce

benzodiazepine use†*

10,25,36,44

Patient refusal, lack of motivation, anxiety Adjust treatment plan with patient input†*; provide patient

education and encouragement†*

9,19,25

Fatigue, need for rest, sleepiness

Safety criteria†*; sleep protocols to improve sleep quality

†*

10,25,27,36

Palliative care

Focus treatment on patient goals for quality of life ‡ 25

ICU devices and equipment



Hemodynamic monitoring equipment

Use portable monitors†*; secure application of equipment

and lines†*

10,12

ICU-related devices Stepwise approach to mobility†*; secure

lines/tubes/drains†; perform pre-mobility planning

†*;

interdisciplinary teamwork†‡

*; define responsibilities for

each discipline†‡

*; strategic choice of catheter insertion

location‡ 9-13,19,27,29,39,43,44,46-48

Abbreviations: BMI: Body Mass Index, PEEP: Positive End Expiratory Pressure, PT: Physical

Therapy

Notes: Some strategies are repeated for more than one barrier because they were reported

as strategies for several barriers.

* Strategy can be used for more than one barrier

† At least one study empirically demonstrated the strategy was successful in improving

mobility rates.

‡ At least one study proposed that the strategy was important in addressing barriers to

mobility based on authors’ opinions



Table 2. Structural barriers to early mobilization and related strategies to overcome barriers

Structural Barriers Strategy (reporting author)

Limited staff, time constraints Additional PT†‡

, OT†, and technician staffing

†*; financial

modeling of economic benefits to increase funds for

staffing†*; independent mobility team

†‡*

10,20,22,23,25,34,42,44-

46,48,49

Lack of early mobility program/protocol (e.g.

no routine delivery of PT), too many existing

protocols, limited guidelines, no eligibility

criteria

Development of protocols†*; evaluation and feedback to

medical team†*; review of safety criteria

†*

10,12,15,19,20,23,26,30,31,34,36,37,40,44,47-49

Inadequate staff training Development of protocols†‡

*; full time therapists

dedicated to ICU†‡

*; stable leadership‡; education

†*;

interprofessional champion†*

10,20,32,37,44-49

Limited equipment Training on appropriate use of equipment†*; cost analysis

and financial modeling of economic benefit†‡

* 10,12,13,19,20,31,44-49

Early discharge (before mobilization)

Planning and coordination of discharge‡ 19

Abbreviations: OT: Occupational Therapy, PT: Physical therapy



mobility rates.





Table 3. ICU cultural barriers to early mobilization and related strategies to overcome

barriers

Cultural barriers Strategies (reporting author)

Lack of mobility culture (e.g.

inadequate staff buy-in, lack of

multidisciplinary culture)

Interprofessional champions†*; promotion of mobility

programs†*; multimedia education

†*; assessment and orders by

RNs‡*; goal sharing

†*; unit-based services

†*; identifying

barriers†‡

* 9,10, 14,19,23,24,30-32,34,36,41,42,44-48

Lack of staff knowledge and expertise

about risks/benefits of mobility

Multiprofessional education and training†‡

* 10,20,30,36,44-48

Early mobility not a priority Assessments and decisions by bedside RNs

†‡*; interprofessional

champions†‡

*; screening for appropriate patients†*; experience

sharing†‡

* 10,15,19,20,23,30,34,44-47

Lack of support or staff buy-in Education†*; regular team meetings

†*; physician support

†*;

culture promoting quality improvement†‡

* 15, 19,30,36-38,44-48

Lack of patient/family knowledge

Media engagement and education†‡

30,35

Abbreviations: RN: Registered Nurse, RT: Respiratory Therapist



mobility rates.





Table 4. Process-related barriers to early mobilization and related strategies to overcome

barriers

Process-related barriers Strategy (reporting author)

Lack of planning and coordination

Regular screening for appropriate patients†*;

interprofessional planning and coordination of

procedures†‡

*; interprofessional rounds†‡

*; daily goal

sheets with reminder about mobility†‡

*; mobility

champion†‡

*; interprofessional task force or mobility

team†*

10,19,20,23,27,30-32,34-38,42,44-49

Unclear expectations, roles, and responsibility

Central champion and champion for each profession†*;

nurse-driven protocol†‡

*; interprofessional

communication and cooperation†‡

* 10,19,20, 24,28,32,36,37,42,

44-48

Missing/delayed daily screening for eligibility,

and standing bedrest order

Mobility team†*; automatic therapy order

†*; daily

screening for eligibility†*; implementation of

protocol†‡

*; coordinators for in-/exclusion†‡

*;

education†*

10,20,23,26, 30,31,37,44-48

Risks for mobility providers (stress, injuries) Training†*, defining roles and responsibilities

†*, re-

prioritizing‡*, screening staff risks

‡, appropriate

equipment‡*, Mobility team

†*, champions

†*

36,44



mobility rates.





Online Data Supplement

Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units

Rolf Dubb, Peter Nydahl, Carsten Hermes, Norbert Schwabbauer, Amy Toonstra, Ann M. Parker,

Arnold Kaltwasser, Dale M. Needham



Table E1. Study design

Author &

year

Design Number,

type of ICU,

hospital1

Population, n,

main inclusion

criteria

Assessment of

barriers &

strategies/ type of

survey

Potential

participant

s

Response

rate

Type of

clinician

(%)

Method evaluating

effectiveness of

strategies2

Studies reporting prospectively defined and empirically evaluated barriers 3

Bailey

2007 (9)

Pros.

cohort

study

1 RICU,

community

hospital

Mixed, n=103,

>4d MV

Anecdotal report

of authors/data

evaluation

Multiprof.

Team - -

Objective

measurement

Morris

2008 (23)

Pros.

cohort

study

7 ICUs,

academic

hospital

Medical (I: 165,

K: 165), >48h

MV

Predefined

medical

contraindications

& data evaluation/

data collection

RN, PT - - Objective

measurement

Thomsen

2008 (24)

Cohort

study3

n.r.

Respiratory

failure, n=103

>4d MV

Data evaluation by

authors/evaluatio

n

Multiprof.

Team - -

Objective

measurement

Schweick

ert 2009

(25)

RCT

2 ICUs, 2

academic

hospitals

Medical, (I: 49,

E: 53), expected

duration of MV >

72h

Predefined

medical

contraindications

& data

evaluation/data

collection

OT, PT - - Objective

measurement

Pohlmann

2010 (27)

Cohort

study4

2 ICUs, 2

academic

hospitals

Medical, n=49,

OT & PT during

daily SBT & SAT

Data evaluation by

authors/evaluatio

n

OT, PT - - Objective

measurement

Zanni

2010 (14)

Cohort

study

1 ICU,

academic

hospital

Medical, n=32,

MV ≥4d

Predefined

medical

contraindications

& data

evaluation/data

collection

PT - - Subjective opinion

Garzon-

Serrano

2011 (28)

Obs.

study

1 ICU,

academic

hospital

Surgical, n=63,

all consecutive

patients

Predefined

medical

contraindications

& data

evaluation/data

collection

PT, RN n.r. n.r. Subjective opinion

Perme

2011 (29)

Retr.

Cohort

study

1 ICU,

academic

hospital

cardiovascular

and thoracic, n=

30, femoral

arterial catheter

Predefined

medical

contraindications

& data

evaluation/data

collection

PT - - Objective

measurement

Leditschk

e 2012

(19)

Obs.

study

1 ICU,

academic

hospital

Mixed, n=106,

all patients

Predefined clinical

contraindications

& data

evaluation/data

collection


Titsworth

2012 (34)

Pros.

cohort

study

1 ICU,

academic

hospital

Neurological,

Pre: 77, post: 93,

all consecutive

patients

Predefined clinical

contraindications

& data

evaluation/data

collection

Multiprof.

Team n.r n.r.

Objective

measurement

Winkelma

nn 2012

(35)

Pros.

cohort

study

2 ICUs,

academic

hospital

Medical and

surgical, pre: 20,

post 55, >48h

MV expected

Predefined clinical

contraindications

& data

evaluation/data

Research

assistants - -

Objective

measurement



collection

Berney

2013 (15)

Preval

ence

study

Aust.,

NZ

38 ICUs in

Aust. & NZ

Mixed, n=514,

all consecutive

patients

Predefined clinical

contraindications

& data

evaluation/data

collection

PT,

research

nurse

- - Subjective opinion

Nydahl

2013 (16)

Preval

ence

study

Ger.

116 ICUs,

different

hospitals

116 mixed ICUs,

n=783, all on MV

Literature based

questionnaire /

electronically

survey

Multiprof.

Team n.r.

61% RN,

28% PT,

8%

physicia

n, 2%

other

Subjective opinion

Perme

2013 (11)

Obs.

study

1 ICU,

academic

hospital

cardiovascular

and thoracic,

n=77, femoral

lines

Predefined

medical

contraindications

& data

evaluation/data

collection

PT - - Objective

measurement

Abrams

2014 (13)

Retr.

Cohort

study

1 ICU,

academic

hospital

Medical, n=100,

ECMO

Predefined

medical

contraindications

& data

evaluation/data

collection

PT - - Objective

measurement

Choong

2014 (41)

Retr.,

multic

enter

obs.

study

6 pediatric

ICUs,

different

hospitals

Mixed on 6

PICUs, n=600,

>24h

Predefined

medical

contraindications

& data

evaluation/data

collection

Research

coordinato

rs

- - Subjective opinion

Harold

2015 (50)

Cohort

study

10 ICUs in

Australia, 9

ICUs in

Scotland,

n.r.

514 patients

Predefined

medical

contraindications

& data

evaluation/data

collection


Studies reporting a mix of clinician-perceived barriers and prospectively defined and empirically evaluated barriers

Needham

2010 (10) QIP

1 ICU,

academic

hospital

Medical (pre: 27,

post: 30), MV

≥4d

Predefined

medical

contraindications

& group meetings

Multiprof.

Team - -

Objective

measurement

Bassett

2012 (30) QIP

13 ICUs, 8

academic

hospitals

13 ICUs in US

Predefined

medical

contraindications

& group meetings

Multiprof.

Team n.r. n.r.

Objective

measurement &

clinician survey

Balas

2014 (40)

Prosp.

cohort

study

5 ICUs, 1

step down, 1

oncology

care unit,

academic

hospital

Mixed,

(pre=146, post:

150), MV

Predefined

medical

contraindications

& data

evaluation/data

collection

Multiprof.

Team - -

Objective

measurement

Harris

2014 (42) QIP

2 ICUs, type

of hospital

n.r.

Medical/surgical

and cardiac ICU,

21 patients, 32

RT and RN

Predefined

medical

contraindications

& staff meetings /

survey &

evaluation of

experiences

Multiprof.

Team n.r. n.r. Clinician survey

Studies reporting clinician-perceived barriers only



McWillia

ms 2008

(22)

Obs.

study

1 ICU,

academic

hospital

Usual PT, n=65,

>24h on ICU

Data evaluation by

authors/evaluatio

n documentation


Hildreth

2010 (26)

Cohort

study

1 ICU,

academic

hospital

Surgical (pre: 50,

post: 50), all

patients

Anecdotal report

of barriers/data

evaluation

- - - Objective

measurement

Winkelma

nn 2010

(20)

Qual.

study

2 ICUs,

academic

hospital

33 RNs Interviews/intervi

ews

RN

(number

n.r.)

- 33 RN

(100%) Clinician survey

Butcher

2012 (31) QIP

1 ICU,

academic

hospital

Surgical, (pre:

50, post: 50), all

post operative

patients

medical

contraindications

& group meetings

Multiprof.

Team - -

Objective

measurement

Drolet

2012 (32) QIP

2 ICUs,

community

hospital

Medical, surgical

and IMCU, (pre:

542, post: 784),

hospitalization

>72h

medical

contraindications

& group meetings

Multiprof.

Team - -

Objective

measurement

Engel

2012 (21) QIP

1 ICU,

academic

hospital

Mixed, (pre:

179, post: 294),

all patients

medical

contraindications

& group meetings

Multiprof.

Team - -

Objective

measurement

Genc

2012 (33)

Retr.

cohort

study

1 ICU,

academic

hospital

Mixed, n=31,

obese patients

(BMI >30)

medical

contraindications,

obesity

PT - - Objective

measurement

Balas

2013 (36)

Prosp

mixed

metho

d study

5 ICUs, 1

step down, 1

special care

unit,

academic

hospital

5 ICUs, 1 step

down, 1 special

care unit, 328

clinicians,

voluntary

3 focus sessions, 3

online surveys, 1

educational

evaluation

Multiprof.

Team n.r. n.r. Subjective opinion

Carrother

s 2013

(37)

QIP

4 ICUs, 2

academic, 2

community

hospitals

4 ICUs of San

Francisco Bay

Area

RAND Success

Factors Survey,

AHRQ Hospital

Survey on Patient

Safety Culture /

Survey

Multiprof.

Team

76% RN,

7%

physicia

ns, 18%

other

Objective

measurement

Choong

2013 (38)

Multic

enter

survey,

differe

nt

hospit

als

17 pediatric

ICUs, type of

hospital n-r-

PICUs in Canada,

61 physicians, 27

PT’s

Literature based

questionnaire /

hard copy &

electronically

survey

102

physicians,

35 PTs

64.2%

59.8%

physicia

ns,

77.1%

PTs

Subjective opinion

Damluji

2013 (39)

Prosp.

Cohort

study

1 ICU,

academic

hospital

Medical, n=239,

femoral lines

(venous, arterial,

dialysis)

medical

contraindications,

femoral lines

PT - - Objective

measurement

Talley

2013 (12) QIP

5 ICUs,

academic

hospital

Mixed, n=109,

>48h CRRT

Literature based &

staff meetings /

evaluation of

experiences

Multiprof.

Team - -

Objective

measurement

Jolley

2014 (44) Survey

1 ICU,

academic

hospital

RN, PT,

physicians,

n=203

Questionnaire /

survey

RN, PT,

physicians -

82%

physicia

n, 22%

RN, 86%

PT

Clinician survey

Wang

2014 (43)

Prosp.

cohort

study

2 ICUs, 2

academic

hospitals

Mixed, n=33,

CRRT

medical

contraindications,

CCRT / data

evaluation/data

PT - - Objective

measurement



collection

Barber

2014 (45)

Qualita

tive

Study

1 ICU,

academic

hospital

RN, PT,

physicians, n=25

Interviews /

Interviews

RN, PT,

physicians -

Physician

s (48%),

PT

(28%),

RN (24%)

Subjective opinion

Eakin

2015 (46)

Qualita

tive

Study

1 ICU,

academic

hospital

Clinicians, n=20 Interviews /

Interviews Clinicians - - Clinician survey

Bakhru,

2015 (47)

Teleph

one

Survey

687 ICUs Clinicians, n=687 Interview /

telephone survey Clinicians 73%

RN

leader Subjective opinion

Castro

2015 (48) QIP

1 ICU,

academic

hospital

RN, n=56 Questionnaire RN 63%

a. 66%,

b. 61% c.

64%

Clinician survey

Malone

2015 (49) Survey

554 ICUs,

academic,

community

hospitals

PT, n=2320 Questionnaire /

survey PT 29% PT Clinician survey

Abbreviations: Aust: Australia; CRRT: continuous renal replacement therapy; ECMO: Extra corporal membrane

oxygenation; Ger: Germany; IMCU: adult intermediate care unit; Multiprof: Multiprofessional; MV: mechanically

ventilation; n.r.: not reported; NZ: New Zealand; Obs: observational, OT: Occupational Therapy; PICU: pediatric

Intensive Care Unit; PT: Physiotherapy; Pros: prospective; Qual.: qualitative; QIP: quality improvement project; Retr:

retrospective; RN: Registered Nurse; RT: Respiratory Therapist; SAT: Spontaneous awakening trial; SBT: Spontaneous

breathing trial

1. Academic hospitals include university hospitals, academic affiliated hospitals, teaching hospitals

2. Categories within this column were defined as follows: objective measurement (defined as having at least one of

the included studies demonstrating that the strategy was successful in improving mobility rates); subjective

opinion (defined as having at least one of the included studies in which the authors concluded, based on their

opinions, the strategy was important in addressing barriers to mobility); and clinician survey (defined as clinicians

being surveyed/interviewed for their opinion about success).

3. The study included patients of Bailey, 2007.

4. The study included intervention arm of Schweickert, 2009



Documents

Barriers and Strategies for Early Mobilization of Patients ... and Strategies for... · Nydahl 2013 (16) Preval ence study Ger. 116 ICUs, different hospitals 116 mixed ICUs, n=783,